The mission of Prognosis is to explore the nexus at which healthcare policy meets healthcare practice and how one affects the other. This blog makes readers more aware of the innovations taking place in healthcare delivery, financing and technology and the types of public policies that will encourage further progress.

Healthcare In Focus is a public education initiative of the HLC, created to promote a constructive dialogue about the state and future of American healthcare.

Action Needed for Market Stability, Access to Health Coverage

July 18, 201811:24 am

There is a consensus in this country that people who are struggling with illnesses and have a greater need for healthcare services should not be prevented from acquiring health insurance. Recent actions at the federal level, though, need to be addressed in order for that ideal to be met.

Risk adjustment payments provide financial stability to insurance providers that provide coverage to relatively high numbers of sicker, higher-cost consumers. Without those payments, premiums would become unaffordable for millions of Americans who buy their coverage through small businesses or on their own in the individual insurance market.

And that brings us to the current dilemma.

A federal district court judge ruled in February that the Department of Health and Human Service’s methodology for calculating risk adjustment payments was flawed and impermissible. Subsequently, on July 7, the Centers for Medicare and Medicaid Services (CMS) announced that payments under the risk adjustment program, including amounts already owed for the 2017 benefit year, would be suspended.

This is an issue that carries extraordinary ramifications. It will create more market instability – at a time in which we need just the opposite – and the potential for reduced coverage options for those who have the greatest need for healthcare access. Further, it could result in increased costs to taxpayers if the federal government has to increase premium subsidies.

An analysis by Change Healthcare, a major technology and analytics firm, found that the individual health insurance market attracts an extremely wide range of enrollees in terms of healthcare utilization. In fact, according to Change, the health plans attracting the sickest patients have health costs at least 450 percent higher than the plans with the healthiest clientele. Thus, the need for risk adjustment payments.

CMS has asked the district court judge to reconsider his ruling. We hope he will. Americans with serious healthcare needs should have affordable coverage.